HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 770 FOREST STREET 7/6/2022 iL Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUL 062022
"C1`1iV yr NUii t H ANOC VER
M Form 4 �4FIALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. -
HOUSE: front ack side rear eft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S tem Locatio
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. ity/Town State Zip Code
2. system Owner:
sae (VtJ
Nam
ieiwn
Address(if different from location)
i City/Town Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping (9_J67�2. Quantity Pum ed:Date —
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By.
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GA-6
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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